Understanding Antiretroviral Treatment Adherence Among HIV-Positive Women at Four Postpartum Time Intervals: Qualitative Results from the Kabeho Study in Rwanda

Abstract

As lifelong antiretroviral therapy (ART) for pregnant women is implemented, it is important to understand the attitudes and norms affecting women's postpartum ART adherence. This is a qualitative cross-sectional study of HIV-positive postpartum women (n = 112) enrolled in a 2-year observational prospective cohort in Rwanda. Informed by the Theory of Reasoned Action (TRA), we conducted in-depth interviews with women whose children were 0-6, 7-12, 13-18, or 21-24 months of age to describe factors contributing to adherence and changes over time. Positive ART attitudes reported by women included mothers' health promotion, prevention of infant HIV infection, higher CD4 count, and improved physical appearance. Negative attitudes were few, but included side effects and the lifelong nature of treatment. Learning from people living with HIV (PLHIV) was identified as a norm facilitating adherence; ART adherence was inhibited by fear of disclosure or stigmatization in communities and clinics. Poor adherence behaviors were common immediately after HIV diagnosis, not necessarily during prevention of mother-to-child transmission (PMTCT). Women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children. The TRA was useful in identifying the collective influence of attitudes, norms, and intentions on behavior. Findings suggest that HIV-positive women are vulnerable to poor adherence following HIV diagnosis and around the time of breastfeeding cessation. Lifelong treatment adherence can be supported through PLHIV exemplifying long-term ART use, fewer and less stigmatizing clinic visits, and counseling messages highlighting the benefits of drugs on appearance and illness prevention and incorporating biological feedback.

Level and determinants of postpartum adherence to antiretroviral therapy in the Eastern Cape, South Africa

“…While we assumed that breastfeeding duration will positively influence adherence to ART among postpartum mothers with HIV, our analysis shows that the association is not statistically significant. In contrast to a study that links breastfeeding cessation with adherence challenges [21], our study did not find a significant difference in the level of adherence between mothers that did not initiate breastfeeding, breastfeed for a short duration or those who breastfed for a longer duration. Fear of infecting the baby is one of the main reasons for not initiating breastfeeding [17], and the group of women who did not breastfeed are likely to take adherence seriously, given their concern for not transmitting the virus.…”

“…In such open and honest environment, there is a high tendency for the men to support their partners in ensuring complete adherence to ART in order to eliminate the risk of MTCT of HIV, a goal shared by both parents. In cases where both partners are not honest about their status, fear of stigma would hinder adherence to ART [17,21].…”

“…While we know that adherence to ART declines during the postpartum period, it remains unclear how infant feeding practices influence adherence to ART. Based on a previous study that shows that women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children [21], we assumed in this study that breastfeeding duration may influence adherence to ART. Also, knowing partner's status could create an enabling environment that increases support for adherence; however, the relationship between knowing a partner's status and postpartum adherence has not been explored in the Eastern Cape, South Africa, a resource-constrained province in South Africa with the third largest HIV prevalence in the country.…”

British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018

“…Viral rebound has been demonstrated in women living with HIV postpartum, with the risk greater than in non‐pregnant women with HIV . Adherence can decline in the postnatal period as a result of concerns about side effects, the lifelong nature of treatment, fear of HIV status being shared and fear of HIV‐related stigma within the community and in clinics . It is important to be aware of the potential for compromised adherence, and to provide appropriate support including peer mentoring, which has been shown to improve adherence .…”

Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12‐month cohort study in urban South Africa and rural Uganda

“…In Mpumalanga Province, South Africa, self-reported adherence to ART was 69% among pregnant WLWH [11] and in Zimbabwe, only 40% of women were taking at least 95% of ART by pill count one year postpartum [12]. Qualitative data from sub-Saharan African sites suggest that adherence challenges for pregnant and postpartum WLWH relate to structural barriers to care, community and healthcare stigma, medication side effects, depression, substance use and the overwhelming challenges of poverty, gender norms, and life with a newborn [13][14][15][16][17][18][19][20].…”